Masakatsu Fukuzawa

A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video)

BACKGROUND Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, although it is not widely used in the colorectum because of technical difficulty. OBJECTIVE To examine the current status of colorectal ESDs at specialized endoscopic treatment centers. DESIGN AND SETTING Multicenter cohort study using a prospectively completed database at 10 specialized institutions. PATIENTS AND INTERVENTIONS From June 1998 to February 2008, 1111 colorectal tumors in 1090 patients were treated by ESD. MAIN OUTCOME MEASUREMENTS Tumor size, macroscopic type, histology, procedure time, en bloc and curative resection rates and complications. RESULTS Included in the 1111 tumors were 356 tubular adenomas, 519 intramucosal cancers, 112 superficial submucosal (SM) cancers, 101 SM deep cancers, 18 carcinoid tumors, 1 mucosa-associated lymphoid tissue lymphoma, and 4 serrated lesions. Macroscopic types included 956 laterally spreading tumors, 30 depressed, 62 protruded, 44 recurrent, and 19 SM tumors. The en bloc and curative resection rates were 88% and 89%, respectively. The mean procedure time ± standard deviation was 116 ± 88 minutes with a mean tumor size of 35 ± 18 mm. Perforations occurred in 54 cases (4.9%) with 4 cases of delayed perforation (0.4%) and 17 cases of postoperative bleeding (1.5%). Two immediate perforations with ineffective endoscopic clipping and 3 delayed perforations required emergency surgery. Tumor size of 50 mm or larger was an independent risk factor for complications, whereas a large number of ESDs performed at an institution decreased the risk of complications. LIMITATIONS No long-term outcome data. CONCLUSIONS ESD performed by experienced endoscopists is an effective alternative treatment to surgery, providing high en bloc and curative resection rates for large superficial colorectal tumors.

Risk of lymph node metastasis in patients with pedunculated type early invasive colorectal cancer: A retrospective multicenter study

Depth of invasion in early invasive colorectal cancer is considered an important predictive factor for lymph node metastasis. However, no large‐scale reports have established the relationship between invasion depth of pedunculated type early invasive colorectal cancers and risk of lymph node metastasis. The aim of this retrospective cohort study was to clarify the risk of lymph node metastasis in pedunculated type early invasive colorectal cancers in a large series. Patients with pedunculated type early invasive colorectal cancer who underwent endoscopic or surgical resection at seven referral hospitals in Japan were enrolled. Haggitt’s line was used as baseline and the invasion depth was classified into two groups, head invasion and stalk invasion. The incidence of lymph node metastasis was investigated between patients with head and stalk invasion. We analyzed 384 pedunculated type early invasive colorectal cancers in 384 patients. There were 154, 156, and 74 endoscopic resection cases, endoscopic resection followed by surgical operation, and surgical resection cases, respectively. There were 240 head invasion and 144 stalk invasion lesions. Among the lesions treated surgically, the overall incidence of lymph node metastasis was 3.5% (8/230). The incidence of lymph node metastasis was 0.0% (0/101) in patients with head invasion, as compared with 6.2% (8/129) in patients with stalk invasion. Pedunculated type early invasive colorectal cancers pathologically diagnosed as head invasion can be managed by endoscopic treatment alone. (Cancer Sci 2011; 102: 1693–1697)

Conflicting clinical environment about the management of antithrombotic agents during the periendoscopic period in Japan

Background and Aims:  Although there are guidelines for the management of antithrombotic agents during the periendoscopic period, gaps between various guidelines create a confusing situation in daily clinical practice. The purpose of this study was to examine the current management of antithrombotic agents during the periendoscopic period in Japan.

Helicobacter pylori infection and reflux esophagitis in young and middle‐aged Japanese subjects

Background and Aims:  Helicobacter pylori infection rates are reported to be high in people over the age of 40 years, but are decreasing in younger age groups. A negative correlation has been reported between H. pylori infection and reflux esophagitis (RE).

CLINICAL EVALUATION OF EMERGENCY ENDOSCOPIC HEMOSTASIS WITH BIPOLAR FORCEPS IN NON‐VARICEAL UPPER GASTROINTESTINAL BLEEDING

The present study was designed to evaluate the usefulness and safety of bipolar hemostatic forceps, known as a less invasive and highly safe means of thermal coagulation used for hemostasis in cases of non‐variceal upper gastrointestinal bleeding. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis. The study involved 39 cases where hemostasis was attempted with bipolar forceps to deal with non‐variceal upper gastrointestinal bleeding, including 28 cases of gastric ulcer, six cases of duodenal ulcer, three cases of bleeding after endoscopic submucosal dissection (ESD), one case of Mallory‐Weiss syndrome and one case of postoperative bleeding from the anastomosed area. There were 34 males and five females, with a mean age of 63.6 years. Bipolar forceps were the first‐line means of hemostasis in cases of oozing bleeding (venous bleeding), pulsatile or spurting bleeding (arterial bleeding) and exposed vessels without active bleeding. The primary hemostasis success rate was 92.3%, and the re‐bleeding rate was 0%. In cases where the bleeding site was located along the tangential line or in cases where large respiration‐caused motions hampered identification of the bleeding site, hemostasis by means of coagulation was easily effected by application of electricity while the forceps were kept open and compressed the bleeding area. In addition, there were no complications. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis.

Narrow‐band imaging on screening of esophageal lesions using an ultrathin transnasal endoscopy

Background and Aim:  Ultrathin transnasal endoscopy, used extensively in Japan, is considered to have inferior image quality and suction performance, and questionable diagnostic performance. So the aim of the present study was to compare the diagnostic performance of white light (WL) examination and non‐magnified narrow‐band imaging (NBI) examination in screening for esophageal disorders with ultrathin transnasal endoscopy.

Endoscopic Submucosal Dissection of a Large Laterally Spreading Tumor in the Rectum is a Minimally Invasive Treatment

3 65-year-old man was referred for endoscopic removal of a large (13 cm), laterally spreading, granular-type tumor in he rectum with its distal margin located 0.5 cm from the entate line (Figure A). The lesion was classified as intramucoal by magnified chromoendoscopy.1 Endoscopic submucosal dissection (ESD) was performed uner conscious sedation using a bipolar current needle knife B-knife; XEMEX Co, Tokyo, Japan; Figure B) and an insulationipped electrosurgical knife (IT knife; Olympus Optical Co, okyo, Japan).2,3 No major complications occurred and the otal duration of the procedure was 3 hours (Figure C). The pecimen was retrieved en bloc and measured 12 9 cm Figure D). Histologic assessment revealed a well-differentited adenocarcinoma limited to the mucosal layer without ny evidence of vascular infiltration and/or poorly differeniated adenocarcinoma component. We report an ESD of a large, rectal, laterally spreading, ranular-type tumor with its distal margin located close to the entate line. In this case, ESD was technically easier and safer to erform in addition to having lower rates of morbidity and ortality compared with other treatment modalities.

Mucosal cutting biopsy technique for histological diagnosis of suspected gastrointestinal stromal tumors of the stomach

The Japanese Gastrointestinal Stromal Tumor (GIST) therapeutic guidelines recommend endoscopic ultrasound‐guided fine‐needle aspiration biopsy for histological diagnosis. However, before 2010, this technique was only carried out at a minority of medical institutions in Japan. In the present study, we investigated the usefulness of mucosal cutting biopsy.

Surveillance of short-segment Barrett's esophagus using ultrathin transnasal endoscopy

Newly developed ultrathin transnasal endoscope, the GIF‐XP290N, makes possible a resolving power similar to the GIF‐H260 at a distance of 3 mm. We conducted surveillance of subjects with Barretts esophagus using this ultrathin transnasal endoscopy. In Japan the lower margin of the lower esophageal palisade vessels is defined the gastroesophageal junction in deep inspiration. We diagnose Barretts esophagus if columnar epithelium is present on the oral side of the gastroesophageal junction.

Clinical impact of endoscopy position detecting unit (UPD-3) for a non-sedated colonoscopy.

AIM To evaluate whether an endoscopy position detecting unit (UPD-3) can improve cecal intubation rates, cecal intubation times and visual analog scale (VAS) pain scores, regardless of the colonoscopists level of experience. METHODS A total of 260 patients (170 men and 90 women) who underwent a colonoscopy were divided into the UPD-3-guided group or the conventional group (no UPD-3 guidance). Colonoscopies were performed by experts (experience of more than 1000 colonoscopies) or trainees (experience of less than 100 colonoscopies). Cecal intubation rates, cecal intubation times, insertion methods (straight insertion: shortening the colonic fold through the bending technique; roping insertion: right turn shortening technique) and patient discomfort were assessed. Patient discomfort during the endoscope insertion was scored by the VAS that was divided into 6 degrees of pain. RESULTS The cecum intubation rates, cecal intubation times, number of cecal intubations that were performed in < 15 min and insertion methods were not significantly different between the conventional group and the UPD-3-guided group. The number of patients who experienced pain during the insertion was markedly less in the UPD-3-guided group than in the conventional group. Univariate and multivariate analysis showed that the following factors were associated with lower VAS pain scores during endoscope insertion: insertion method (straight insertion) and UPD-3 guidance in the trainee group. For the experts group, univariate analysis showed that only the insertion method (straight insertion) was associated with lower VAS pain scores. CONCLUSION Although UPD-3 guidance did not shorten intubation times, it resulted in less patient pain during endoscope insertion compared with conventional endoscopy for the procedures performed by trainees.